Evidence-Based Practice and Practice-Based Evidence

1. Evidence-Based Practice and Practice-Based Evidence KNR 365

2. Rationale: ATRA Standards of Practice • Standard 2: The recreational therapist plans and develops an individualized treatment plan that identifies goals and evidence-based treatment intervention strategies. • Standard 3: The recreational therapist implements an individualized treatment plan, using evidence-based practice…. • Snethen & McCormick, 2013

3. Rationale: ATRA Code of Ethics • Principle 1: Beneficence • Recreational Therapy personnel shall treat persons served in an ethical manner by actively making efforts to provide for their well-being by maximizing benefits and relieving, lessening, or minimizing possible harm. • Principle 2: Non-Maleficence • Recreational Therapy personnel have an obligation to use their knowledge, skills, abilities, and judgment to help persons while respecting their decisions and protecting them from harm. • ATRA, 2009

4. Rationale: ATRA Code of Ethics • Principle 9: Competence • Recreational Therapy personnel have the responsibility to maintain and improve their knowledge related to the profession and demonstrate current, competent practice to persons served. In addition, personnel have an obligation to maintain their credential. • ATRA, 2009

5. How do we get from assessment/goals to intended outcomes?

6. Well Designed Interventions/Implementation Strategies

7. Evidence-Based Practice • Began as evidence-based medicine • Research • Physicians failed to recommend medications up to 10 years after they had been shown to be effective • Continue to recommend treatments up to 10 years after they have been shown to be useless • Hall, 2007 • Now used with other disciplines

8. Definition • Conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients • Sackett, Rosenberg, Gray, Haynes, Richardson, 1996 • Evidence used to support proposed course of treatment • Finding treatments that work based on results from research

9. Evidence-Based Practice& Therapeutic Recreation • Evidence-based practice is the process of applying results of outcomes research to improve services to clients • It is the selection of treatments for which there is some evidence of efficacy • More than professional judgment • Stumbo & Peterson, 2009 • Practitioners should not select programs because we have always done it that way or based on out-dated information • Austin, 2009 • No TR program should be proposed without a serious search of the research literature for support • Patrick & Magnuson, 2001

10. Benefits • Increased chance of getting to client outcomes quickly • Rationale or justification of programs • Standardize practice/reduce variability between agencies & practitioners • Talk with other disciplines • Stumbo & Peterson, 2004 • Improves practitioner knowledge • Accountability • Bennet, n.d.

11. Benefits • Improve clinical practice & client care • May not tell us what to do but can warn us what not to do • Reduces risks & possible harm • Reduce costs & unnecessary treatment

12. Evidence-Based Practice Goes Beyond Google

13. EBP accomplished in 4 ways • Following 5 step process • Seeking evidence collected by others • Adopting protocols written by others • Stumbo, 2003 • Systematic reviews • Coyle, et al., 2008

14. Evidence-Based Practice:5 Step Process (Stumbo, 2009) • Formulate a question about a client problem • Patient or problem being addressed • What interventions work best with veterans who are homeless? Who have substance abuse problems? • Intervention being considered • Is there sufficient evidence for the inclusion of aerobic exercise as a treatment for people with major depressive diagnoses? • Another intervention for comparison • Will a middle-aged person with a recent spinal cord injury gain greater stress reduction from yoga or tai chi? • Possible prevention strategy • Outcomes

15. 5 Step Process 2. Search databases for relevant clinical evidence/research 3. Appraise the evidence • Level I: Strong evidence from at least 1 systematic review of multiple well-designed randomized controlled trials • Level II: Strong evidence from at least 1 properly designed, randomized controlled trial of appropriate size • Level III: Evidence from well designed trials such as nonrandomized trials, comparative or correlational studies • Level IV: Evidence from well-designed, nonexperimental studies from more than 1 center or research group • Level V: Opinions of respected authorities based on clinical evidence, descriptive studies, or reports of expert committees

16. Evidence-Based Practice:Appraise the Evidence • How strong is the research? • Is the population similar to mine? • Is the agency similar to mine? • What was used to measure outcomes? • Reliable • Valid • What treatment was used? • What were the results of the study? • What are the limitations of the study? • Are there resources available to implement the program/intervention? Ross & Ashton-Shaeffer, 2003

17. 5 Step Process 4. Implement & use findings in practice 5. Evaluate the impact of change in practice

18. Evidence-Based Practice:Search for Research Evidence – Where? • Therapeutic Recreation Journal • Annual in Therapeutic Recreation • American Journal of Recreation Therapy • Palaestra • Journal of Physical Education, Recreation & Dance • Leisure Sciences • Journal of Leisure Research

19. Evidence-Based Practice:Search for Research Evidence – Where? • Not all TR research in TR journals • Journal of Rehabilitation • New England Journal of Medicine • American Journal of Public Health • Pediatrics • Indexes • CINAHL • PubMed • PsycINFO

20. Evidence-Based Practice:Search for Research Evidence – Where? • Treatment Networks (ATRA Newsletter) • Books (Sagamore, Venture, Idyll Arbor) • Therapeutic Recreation and the Nature of Disabilities • Mobily & MacNeil, 2002

21. Evidence-Based Practice:Search for Research Evidence – Where? • Benefits of Therapeutic Recreation: A Consensus View • Coyle, Kinney, Riley & Shank, 1991 • Population groups • Chemical dependency • Developmental disabilities • Gerontology • Pediatrics • Physical Medicine • Psychiatry

22. West, 2009 • “Until more evidence is available about specific interventions used by recreational therapists, evidence of the benefits of interventions used by allied disciplines and also used by recreational therapists should be studied to determine the related value for recreational therapy practice.” • p. 261

23. Evidence-Based Practice:Search for Research Evidence – Where? • Facilitation of Therapeutic Recreation Services: An Evidence-Based and Best Practice Approach to Techniques and Processes • Stumbo & Wardlaw, 2011

24. Richeson, Fitzsimmons, & Buettner (2009) • “Currently other professions, including nursing, psychology, social work, occupational therapy, and others provide the majority of evidence for recreational therapy.” • P. 273

25. Systematic Reviews • “Systematic reviews are summaries of research findings that can guide healthcare practice. Systematic reviews involve the use of explicit methods to identify and evaluate research studies in a particular area” (Coyle et al., 2008, p. 14). • “Systematic reviews differ from literature reviews. Systematic reviews use all relevant literature from multiple sources, published and unpublished, and there is a more rigorous and systematic appraisal and evaluation” (Research and Evidence Based Practice, p. 56).

26. Coyle, Denault, Miller, Pham, Thomas (2008) • Understanding systematic reviews and their implications for evidence-based practice by examining aerobic exercise as a recreational therapy intervention for individuals with major depressive disorders. • American Journal of Recreational Therapy, 7(3)

27. Systematic Reviews Outcomes • Practice-focused guidelines • Dementia Practice Guidelines for Recreational Therapy: Treatment of Disturbing Behaviors • Buettner & Fitzsimmons, 2008

28. Evidence-Based Practice:Search for Research Evidence – Where? • Cochrane Collaboration • http://www.cochrane.org/ • OT Seeker • http://www.otseeker.com/ • SAMHSA’s National Registry of Evidence-based Programs & Practices • http://www.nrepp.samhsa.gov/

29. Evidence-Based Practice:Search for Research Evidence – Where? • Clinical Evidence • http://clinicalevidence.bmj.com/ceweb/index.jsp • Hooked on Evidence (PT) • http://www.hookedonevidence.com/ • National Guideline Clearinghouse • http://www.guideline.gov/

30. Evidence-Based Practice:Search for Research Evidence – Where?Temple University RT Wise Owlshttp://rtwiseowls.com

31. Concerns • Standardization • Erosion of autonomy of practitioner • Lack of relevant research • Impact of using other professions research? Pros/Cons • Studies may not reflect “real world” conditions • Studies may not fully describe intervention

32. Concerns • Most quantitative experimental studies are based on group means • Practitioners have a hard time understanding research • Or doing research • Not an easy process to do • Time consuming • Implementing EBP

33. Research Utilization • Subset of EBP • Use of research knowledge often based on a single study • Bennet, 2009 • Use of research findings to improve client care

34. Research Utilization:Example • The Association Between Healthy Lifestyle Behaviors and Relapse Rates in a Homeless Veteran Population • The American Journal of Drug and Alcohol Abuse • LePage & Garcia-Rea, 2008 • Veterans participating in more Healthy Lifestyle Behaviors were associated with lower relapse and return to homelessness

35. Theory-Based Practice • “Although there is a strong argument for evidence-based interventions, these are not always possible or desired in all situations. Despite that, even small, highly idiosyncratic programs can benefit from using logic models to specify a theory of intervention and explanation.” • Caldwell, 2003, p. 82

36. Theory-Based Practice • Using theory as the basis for program design • Self-efficacy • Stress-coping • Flow

37. Theory-Based Practice:Stress-Coping Theory • Carruthers & Hood (2002) • Coping skills program for individuals with alcoholism

38. Practice-Based Evidence PBE

39. Practice-Based Evidence • “In the concept of Practice-Based Evidence, the real, messy, complicated world is not controlled. Instead, real world practice is documented and measured, just as it occurs, ‘warts’ and all. It is the process of measurement and tracking that matters, not controlling how practice is delivered.” • Swisher, 2010, p. 4

40. Practice-Based Evidence • Defined: Gathering of good data from routine practice • Emphasizes outcome evidence based in the real world • Interventions that are widely practiced • Gives voice to practitioners & service users • Reflective practitioner carefully describes the client, intervention, and outcomes. • Aggregates approaches to look at larger trends that work in the field

41. Practice-Based Evidence • Outcomes are differences in client behaviors, knowledge, skills, etc. Assessment Outcome Intervention

42. Practice-Based Evidence:Example from Literature • Running from Homelessness

43. Documenting Outcomes • Meet goals & objectives of program/treatment plan • Carruthers & Hood, 2002 • Self report of involvement • LePage & Garcia-Rea, 2008 • Increased score on scale or instrument • Wise, Ellis, & Trunneil, 2002

44. Documenting Outcomes:Growing Practice-Based Evidence • Therapeutic Recreation Journal • Practice Perspectives • Case Reports • “It Gives Me Purpose”: The use of Dance with People Experiencing Homelessness • Knestaut, Devine, & Veriezza • Vol. XLIV, No. 4, pp. 289-301

45. Documenting Outcomes:Growing Practice-Based EvidenceATRA Research Institute Practice Posters • Poster Title • Intervention Program Overview • Brief synopsis of program including setting & population. Is there support from the literature? • Client goals • Assessment tools/techniques • Who is appropriate for the program? Inclusion criteria?Referral to program? • Staffing • Process • Describe how program is implemented. Frequency. Number of sessions • Evaluation • How the program is evaluated • Client outcomes • Suggestions for replication • How can another therapist do this program?

46. PBE does not replace EBP but adds to it! Interventions Practice Research RT Implementation Strategies